Diabetes Mellitus Algorithm R: Kidney Function

Patient with DM and no kidney evaluation in past 12 months [A]
1. Screen for microabuminuria: - Measure random urine for Alb/Cr ratio OR - 24 hour urine collection for protein and creatinine [B]
Obtain serum creatinine and estimate GFR [C]
Is urine Alb/Cr greater than or equal to 30 micrograms per mg confirmed? [D] Is urine Alb/Cr ratio greater than or equal to 300 micrograms per mg or 24 hour urine protein greater than or equal to 300 micrograms over 4 hours? [E] Is diabetic nephropathy suspected (excluding non-diabetes kidney disease)? [F]
Box 3 no to box 16 Box 4 no to box 7 Refer to nephrology [H]
Is serum creatinine greater than 1.4 mg/dL or eGFR less than 60 ml/min? [G] Consider referral or consult with nephrology. Re-evaluate for non-diabetic cause for elevated creatinine [H]
Assess and maintain glycemic control. See Module G Is there identifiable cause for elevated creatinine?
Start/adjust treatment with ACEI. If adverse effects to ACEI, change to ARB. Check serum potassium prior to starting therapy and repeat in 2 to 4 weeks [I] Refer to nephrology [H] Treat as indicated
Is HBA1c greater than 8 percent or blood pressure greater than 140over 80? [J] Continue to adjust treatment to achieve target using Hypertension Guideline and Glycemic Control Module
Monitor random urine protein : creatinine ratio and serum creatinine (eGFR). Adjust treatment and follow up annually [K] Box 5 yes to box 18
Continue DM management. Return to Module D Box 5 yes to box 18
Patient with DM and urine protein : creatinine ratio greater than 30 micrograms per mg or confirmed nephropathy
Is renal insufficiency present (serum creatinine greater than 2.0 mg/dL or eGFR less than 50 ml/min)? [H] Refer or consult with nephrology to ensure optimal management and plan for ESRD
Consider counseling patient on reduced protein diet [L]
Start/adjust treatment with ACE Inhibitor. If adverse effects to ACEI, change to ARB. Check serum potassium and creatinine prior to starting ACEI and reapeat in 2 to 4 weeks [I]
Manage blood-pressure using Hypertension Guideline to slow progression of nephropathy
Are there side effects to ACEI treatment? [M] Stop ACEI treatment; change to ARB [N]
Monitor random urine protein : creatinine and serum creatinine (eGFR) every 6 months. Adjust treatment and follow up as indicated [O]
Is renal insufficiency present (serum creatinine greater than 2.0 mg/dL or dGFR less than 50 ml/min)? [H] Refer to nephrology to ensure optimal management and plan for ESRD
Continue DM management. Return to Module D